Ulcers at the tip of a lesser toe are among the most stubborn wounds in diabetic foot care. They sit where conventional offloading devices reach poorly, lie directly over bone with almost no soft-tissue buffer, and progress to osteomyelitis and digital amputation with disquieting speed. The standard response was long footwear modification, toe props and repeated debridement — an approach that healed some ulcers slowly and allowed many to recur. Over the past decade, a minimally invasive procedure taking minutes in an outpatient setting has accumulated enough evidence to change that default: percutaneous flexor tendon tenotomy is now a guideline-endorsed intervention for toe ulcers caused by flexible claw and hammer toe deformity.
Why Toe Deformity Drives Toe Ulceration
Diabetic peripheral neuropathy produces an imbalance between the intrinsic foot muscles and the long flexor and extensor tendons. The result is the familiar claw or hammer toe: the metatarsophalangeal joint extends while the interphalangeal joints flex, lifting the toe pulp off the ground and driving the apex of the toe into the insole with every step. Pressure normally spread across the plantar surface of the digit concentrates onto a few square millimetres of skin over the distal phalanx.
The deformity is not uniform, and the distinction matters. Sanz-Corbalán and colleagues, in a cross-sectional study of 142 feet in the Journal of Foot and Ankle Surgery (2019), classified digital deformities dynamically using the McGlamry system. Flexor stabilization was most prevalent, significantly associated with pronated foot posture, apical callus and previous tip-of-toe ulceration. Roughly 40% of feet showed extensor substitution — a pattern in which releasing the long flexor may worsen rather than correct the deformity. Dynamic assessment during gait, not a static look at a bent toe, identifies who will benefit.
What the Procedure Does Mechanically
Flexor tendon tenotomy transects the flexor digitorum longus tendon percutaneously — classically through a small stab incision, increasingly with a needle — allowing the flexed interphalangeal joints to extend and the toe to rest flat. Mens and colleagues, writing in Diabetic Medicine (2022), measured dynamic barefoot plantar pressure and weight-bearing radiographs before and 2–4 weeks after needle tenotomy in 14 patients (50 toes, 19 feet). Mean peak pressure at the toe fell by 279 kPa (95% CI 204–353), and joint angles decreased significantly at the metatarsophalangeal (7°), proximal interphalangeal (19°) and distal interphalangeal (28°) joints. No ulcer recurred over a mean 11.4 months. The procedure is not simply a wound treatment; it removes the mechanical cause of the wound.
Healing and Recurrence Outcomes
Scott, Hendry and Locke published the first systematic review in the Journal of Foot and Ankle Research (2016), pooling five case series covering 250 tenotomies in 163 patients. Healing was 92–100% within two months, recurrence 0–18% at a median 22 months, complications infrequent. The authors were appropriately cautious: all included studies were uncontrolled case series, yielding only level 4 evidence.
A larger systematic review by Calvo-Wright and colleagues in the Journal of Clinical Medicine (2023) analysed 11 studies and reported the same healing range of 92–100%, with a mean healing time of two to four weeks and a low recurrence rate. Complications were mild, the most common being the transfer lesion — a new ulcer on an adjacent, untreated toe as load redistributes — which the authors noted is largely eliminated by tenotomy of all lesser toes simultaneously. Healing in two to four weeks, for wounds that had often persisted months, reflects how small, non-ischaemic and mechanically driven these ulcers usually are.
Guideline Position and Remaining Uncertainty
The 2023 International Working Group on the Diabetic Foot offloading guideline, authored by Bus and colleagues in Diabetes/Metabolism Research and Reviews, states that for a neuropathic plantar or apex lesser-digit ulcer secondary to flexible toe deformity, digital flexor tendon tenotomy should be used. This is notable: for most other offloading questions the guideline reserves surgery for cases where non-surgical treatment has failed. For the flexible clawed toe, tenotomy is first-line rather than salvage.
Randomised evidence remains thin. The DIAFLEX trial, whose protocol Mens and colleagues published in Contemporary Clinical Trials Communications (2023), randomises 66 participants with a history of toe ulceration to tenotomy versus standard orthotic and footwear offloading, with recurrence as the primary endpoint. A recent review by Kirketerp-Møller and Saysoukha in Clinics in Podiatric Medicine and Surgery (2026) notes that while healing exceeds 90% and complications are minor, longer-term risks of new ulceration elsewhere in the foot and of amputation are not abolished by the procedure.
A service evaluation by Heald and colleagues in the Journal of Foot and Ankle Research (2026) compared needle tenotomies done by a senior podiatrist with those done by an orthopaedic surgeon. Despite a podiatrist-led group that was older, with higher HbA1c and longer-standing ulcers, healing rates and time to resolution did not differ significantly, at roughly half the cost of a day-case theatre procedure.
Clinical Summary
For an apical or plantar lesser-toe ulcer in a neuropathic foot with a flexible claw or hammer toe deformity, percutaneous flexor tenotomy reduces toe pressure substantially, heals most ulcers within two to four weeks, and carries a low complication burden. Selection depends on establishing that the deformity is flexible and that the dynamic pattern is one the procedure will correct; perfusion must be confirmed, infection addressed, and adjacent toes considered to limit transfer lesions. The procedure does not treat the neuropathy that produced the deformity, so surveillance, footwear provision and foot protection remain necessary after healing. Randomised evidence on long-term recurrence prevention is still awaited.
References
Bus SA, Armstrong DG, Crews RT, et al. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3647.
Scott JE, Hendry GJ, Locke J. Effectiveness of percutaneous flexor tenotomies for the management and prevention of recurrence of diabetic toe ulcers: a systematic review. Journal of Foot and Ankle Research. 2016;9:25.
Calvo-Wright MM, López-Moral M, García-Álvarez Y, et al. Effectiveness of percutaneous flexor tenotomies for the prevention and management of toe-related diabetic foot ulcers: a systematic review. Journal of Clinical Medicine. 2023;12(8):2835.
Mens MA, van Netten JJ, Busch-Westbroek TE, et al. Biomechanical and musculoskeletal changes after flexor tenotomy to reduce the risk of diabetic neuropathic toe ulcer recurrence. Diabetic Medicine. 2022;39(4):e14761.
Sanz-Corbalán I, Lázaro-Martínez JL, García-Álvarez Y, et al. Digital deformity assessment prior to percutaneous flexor tenotomy for managing diabetic foot ulcers on the toes. Journal of Foot and Ankle Surgery. 2019;58(3):453-457.
Mens MA, Busch-Westbroek TE, Bus SA, et al. The efficacy of flexor tenotomy to prevent recurrent diabetic foot ulcers (DIAFLEX trial): study protocol for a randomized controlled trial. Contemporary Clinical Trials Communications. 2023;33:101107.
Kirketerp-Møller K, Saysoukha V. Flexor tendon tenotomy in diabetic toe ulcers: evidence and clinical application. Clinics in Podiatric Medicine and Surgery. 2026;43(2):219-224.
Heald A, Veluchamy Rathakrishnan SP, Blong J, et al. Comparative outcomes of percutaneous needle tenotomy performed by a podiatrist versus an orthopaedic surgeon in the management of toe ulcers. Journal of Foot and Ankle Research. 2026;19(1):e70123.
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